Clinical Significance

of
Dental Anatomy ,
Histology , Physiology ,
and Occlusion

Structures of the teeth

The teeth are composed of enamel, pulpdentin complex, and cementum .
ENAMEL:
Enamel is formed by cells called
ameloblasts, which originate from the
embryonic germ layer known as ectoderm
Ameloblasts have short extensions toward
the dentinoenamel junction (DEJ); these
are termed Tomes processes

 Structurally, enamel is composed of millions of

enamel rods or prisms, which are the largest
structural components.
The hardest substance of the human body is
enamel. Hardness may vary over the external
tooth surface according to the location; also, it
decreases inward, with hardness lowest at the
DEJ. The density of enamel also decreases from
the surface to the DEJ. Enamel is a very brittle
structure with a high elastic modulus and low
tensile strength, which indicates a rigid structure.

 Enamel requires a base of dentin to

withstand masticatory forces. Enamel
rods that fail to possess a dentin base
because of caries or improper
preparation design are easily
fractured away from neighboring rods.
For maximal strength in tooth
preparation, all enamel rods should be
supported by dentin

 The changes in direction of enamel prisms that

minimize cleavage in the axial direction produce an
optical appearance called Hunter-Schreger bands.
These bands are found in different areas of each
class of teeth. Since the enamel rod orientation
varies in each tooth, Hunter- Schreger bands also
have a variation in the number present in each
tooth. In the anterior teeth they are located near
the incisal surfaces. They increase in numbers and
areas of the teeth from the canines to the
premolars. In the molars the bands occur from near
the cervical region to the cusp tips.

 Deep invaginations occur in pit-and-fissure areas of

the occlusal surfaces of premolars and molars; such
invaginations decrease enamel thickness in these
areas.
These fissures act as food and bacterial traps that
may predispose the tooth to dental caries. Occlusal
grooves, which are sound, serve an important
function as an escape path for the movement of
food to the facial and lingual surfaces during
mastication. A functional cusp that opposes a
groove occludes on the enamel inclines on each side
of the groove and not in the depth of the groove.

 Enamel is incapable of repairing itself once

destroyed and because the ameloblast cell
degenerates following formation of the
enamel rod. The final act of the ameloblast
cell is secretion of a membrane covering
the end of the enamel rod. This layer is
referred to as the Nasmyth membrane, or
the primary enamel cuticle. This membrane
covers the newly erupted tooth and is worn
away by mastication and cleaning

 Enamel is soluble when exposed to an acid

medium ,but the dissolution is not uniform.
Solubility of enamel increases from the enamel
surface to the DEJ. When fluorides are present
during enamel formation or are topically applied
to the enamel surface, the solubility of surface
enamel is decreased. Fluoride concentration
decreases toward the DEJ. Fluoride additions can
affect the chemical and physical properties of the
apatite mineral and influence the hardness,
chemical reactivity, and stability of enamel while
preserving the apatite structures.

 An established operative technique

involves acid etching the enamel
surface for the micromechanical
bonding" of composite restorative
materials or pit and-fissure sealants
directly to the etched surface.

Pulp-Dentin Complex
Dentin and pulp tissues are specialized
connective tissues of mesodermal origin,
formed from the dental papilla of the
tooth bud. These two tissues are
considered by many investigators as a
single tissue, which thus form the pulpdentin complex, with mineralized dentin
comprising the mature end product of cell
differentiation and maturation. Dentin is
formed by cells called odontoblasts.

 The surface area of dentin is much larger at the

dentinoenamel or dentinocemental junction than it
is on the pulp cavity side. Since the odontoblasts
form dentin while progressing inward toward the
pulp, the tubules are forced closer together. The
number of tubules increases from 15,000 to
20,000/mmz at the DEJ to 45,000 to 65,000/mmz
at the pulp.' The lumen of the tubules also varies
from the DEJ to the pulp surface. In coronal dentin,
the average diameter of tubules at the
dentinoenamel junction is 0.5 to 0.9 /-tm, but this
increases to 2 to 3 /.Lm at the pulp.

 Dentin is significantly softer than enamel

but harder than bone or cementum. The
hardness of dentin averages one fifth that
of enamel, and its hardness near the DEJ
is about three times greater than near the
pulp.
Dentin becomes harder with age, primarily
due to increases in mineral content. While
dentin is a hard, mineralized tissue

 During tooth preparation, dentin is usually distinguished

from enamel by: (1) color, (2) reflectance, (3) hardness, and
(4) sound.
Dentin is normally yellow white and slightly darker than
enamel. In older patients dentin is darker, and it can
become brown or black in cases where it has been exposed
to oral fluids, old restorative materials, or slowly advancing
caries. Dentin surfaces are more opaque and dull, being
less reflective to light than similar enamel surfaces, which
appear shiny. Dentin is softer than enamel and provides
greater yield to the pressure of a sharp explorer tine, which
tends to catch and hold in dentin. When moving an explorer
tine over the tooth, enamel surfaces provide a sharper,
higher-pitched sound than dentin surfaces.

 Sensitivity is encountered whenever

odontoblasts and their processes are
stimulated during operative procedures,
even though the pain receptor
mechanism appears to be within the
dentinal tubules near the pulp.
A variety of physical, thermal, chemical,
bacterial, and traumatic stimuli are
transmitted through the dentinal tubules,

 Dentin must be treated with great care during

restorative procedures to minimize damage to the
odontoblasts and pulp. Air-water spray should be used
whenever cutting with high-speed handpieces to avoid
heat buildup.
The dentin should not be dehydrated by compressed air
blasts; it should always maintain its normal fluid content
.
Protection is also provided by judicious use of liners,
bases, dentin-bonding agents, and nontoxic restorative
materials.
Restorations must adequately seal the preparation to
avoid microleakage and bacterial penetration

DENTAL PULP
The dental pulp occupies the pulp cavity in the tooth.
Each pulp organ is circumscribed by the dentin and is
lined peripherally by a cellular layer of odontoblasts
adjacent to the dentin.
The dental pulp is composed of myelinated and
unmyelinated nerves, arteries, veins, lymph channels,
connective tissue cells, intercellular substance,
odontoblasts, fibroblasts, macrophages, collagen, and
fine fibers. The central area of the pulp contains the
large blood vessels and nerve trunks. The pulp is
circumscribed peripherally by a specialized
odontogenic area made up of the odontoblasts, the
cell-free zone, and the cell-rich zone

 The pulp is a unique, specialized

organ of the human body serving
four functions:
(1) formative or developmental,
(2) nutritive,
(3) sensory or protective, and
(4) defensive or reparative

 In cases of severe irritation the pulp

responds by an inflammatory reaction
similar to that for any other soft tissue
injury. However, the inflammation may
become irreversible and can result in
the death of the pulp because the
confined, rigid structure of the dentin
limits the inflammatory response and
the ability of the pulp to recover.

 If, however, the irritant is very mild, such as that

caused by cutting the odontoblastic processes
more than 1.5 mm external to the pulp at high
speed with airwater coolant during tooth
preparation, no replacement odontoblasts are
formed; thus no reparative dentin is created, even
though the processes and corresponding
odontoblasts have died. Therefore there is no
barrier (except for the smear layer) between the
dead tracts remaining and the pulp. This may
explain why many teeth have pulpal problems
following tooth preparation and restoration.

 When an irritant (e.g., sugar, cold, acid from

caries) first contacts dentin, the patient may be
alerted by a twinge of pain. This pain is usually
only momentary, ceasing if the irritant is removed.
If such irritation continues or the irritant is applied
repeatedly, hyperemia (increased blood flow and
volume) and inflammation of the pulp can result,
which will cause the pain elicited from the irritation
to linger a few seconds. The reaction is because
the pulp is contained by unyielding dentinal walls;
thus drainage of the increased blood is limited by
the constricted apical foramen.

 As long as an irritant, such as

touching ice to the tooth, causes pain
that lingers no more than 10 to 15
seconds after removal of the irritant,
resolution of the hyperemia by
immediate restorative treatment is a
possibility; such hyperemia is termed
reversible pulpitis.

 When pulpal pain, either spontaneous

or elicited by an irritant, lingers more
than 15 seconds, infection of the pulp
often has occurred and resolution by
operative dentistry treatment is
usually doubtful; root canal therapy is
advised for this pulpal condition,
termed irreversible pulpitis, if the tooth
is to be maintained in the dentition.

 When this condition is untreated,

suppuration and pulpal necrosis
follows, characterized by
spontaneous, continuous throbbing
pain or pain elicited by heat that can
be relieved by cold and later
characterized by no response to any
stimulus. Pulpal necrosis is treated
by root canal therapy or tooth
extraction.

Cementum
Cementum is the hard dental tissue covering
the anatomic roots of teeth and is formed by
cells known as cementoblasts, which develop
from undifferentiated mesenchymal cells in
the connective tissue of the dental follicle.
Cementum is slightly softer than dentin
Sharpey's fibers are the portions of the
collagenous principal fibers of the periodontal
ligament embedded in both the cementum and
alveolar bone to attach the tooth to the
alveolus

 Cementum is avascular.
The cementum is light yellow and slightly
lighter in color than dentin. It has the
highest fluoride content of all mineralized
tissue. Cementum is also permeable to a
variety of materials. It is formed
continuously throughout life, because a
new layer of cementum is deposited to
keep the attachment intact as the
superficial layer of cementum ages.

 In about 10% of teeth, enamel and

cementum do not meet, and this can
result in a sensitive area. Abrasion,
erosion, caries, scaling, and the
procedures of finishing and polishing may
result in denuding the dentin of its
cementum covering, which can cause the
dentin to be sensitive to several types of
stimuli (e.g., heat, cold, sweet and sour
substances).

 Cementum is capable of repairing

itself to a limited degree and is not
resorbed under normal conditions.
Some resorption of the apical portion
of the root often occurs during
physiologic tooth movement

PHYSIOLOGY OF TOOTH
FORM
The teeth serve four main
functions:
mastication,
esthetics,
speech, and
protection of supporting tissues.

Contours
The facial and lingual surfaces possess
some degree of convexity that affords
protection and stimulation of the
supporting tissues during mastication.
This convexity generally is located at
the cervical third of the crown on the
facial surfaces of all teeth and the
lingual surfaces of the incisors and
canines.

 Too little contour may result in trauma to the

attachment apparatus.
These tooth contours must be considered in the
performance of operative dental procedures.
Improper location and degree of facial or lingual
convexities can result in serious complications,
where the proper facial contour is disregarded in the
placement of a cervical restoration on a mandibular
molar.
Overcontouring is the worst offender, usually
resulting in flabby, red-colored, chronically inflamed
gingiva and increased plaque retention

Proximal Contact Area

The physiologic significance of properly formed
and located proximal contacts cannot be
overemphasized; they promote normal healthy
interdental papillae filling of the interproximal
spaces.
Improper contacts can result in food impaction
between the teeth producing periodontal disease,
carious lesions, and possible movement of the
teeth. In addition, retention of food is
objectionable by its physical presence and by the
halitosis that results from food decomposition.

 Proximal contacts and interdigitation of the

teeth through occlusal contacts stabilizes and
maintains the integrity of the dental arches.
The proximal contact area is located in the
incisal third of the approximating surfaces of
the maxillary and mandibular central incisors.
Restorative procedures require maintenance
of correct proximal contact relationships
between teeth, which results in correct
embrasures.

Embrasures
Embrasures are V-shaped spaces that
originate at the proximal contact areas
between adjacent teeth and are named
for the direction toward which they
radiate. These embrasures are:
facial,
lingual,
incisal or occlusal,
gingival

 The correct relationships of embrasures, cusps to

sulci, marginal ridges, and grooves of adjacent and
opposing teeth provide for the escape of food from
the occlusalsurfaces during mastication.
When an embrasure is decreased in size or absent,
additional stress is created in the teeth and the
supporting structures during mastication. Embrasures
that are too large provide little protection to the
supporting structures as food is forced into the
interproximal space by an opposing cusp.
example is the failure to restore the distal cusp of a
mandibular first molar when placing a restoration

 The marginal ridges of adjacent posterior teeth

should be at the same height to have proper
contact and embrasure forms. When this
relationship is absent, there is an increase in
the problems associated with weak contacts
and faulty embrasure form.
Correct anatomic form renders the teeth more
self-cleansing because of the smoothly
rounded contours that are more exposed to
the cleansing action of foods and fluids and
the frictional

movement of the tongue, lips, and

cheeks.
Failure to understand and adhere to
correct anatomic form in the performance
of restorative procedures can contribute
to the breakdown of the stomatognathic
system and the importance of providing
correct anatomic features in restorative
dentistry cannot be overemphasized.

PERIODONTIUM
The periodontium consists of the oral hard
and soft tissues that invest and support the
teeth.
It can be divided into:
the gingival unit, consisting of free and
attached gingiva and the alveolar mucosa,
and
the attachment apparatus, consisting of
the cementum, periodontal ligament, and
alveolar process.

 The periodontal ligament serves the

following functions:
(1) attachment and support,
(2) sensory,
(3) nutritive, and
(4)homeostatic

 Clinically, the level of the gingival attachment and

gingival sulcus is an important factor in restorative
dentistry.
Soft tissue health must be maintained by the teeth
having correct form and position if apical recession
of the gingiva and possible abrasion and erosion of
the roots are to be prevented.
The margin of a tooth preparation should not be
positioned subgingivally (at levels between the
marginal crest of the free gingiva and the base of
the sulcus) unless dictated by caries, previous
restoration, esthetics, or other preparation needs.

OCCLUSION
Occlusion literally means "closing"; in
dentistry,
Occlusion means the contact of teeth
in opposing dental arches when the
jaws are closed (static occlusal
relationships) and during various jaw
movements (dynamic occlusal
relationships).

 Occlusal contact patterns vary with the position of the

mandible. Static occlusion is further defined by use of
reference positions that include fully closed, terminal hinge
closure, retruded, and right and left lateral extremes.
The number and location of occlusal contacts between
opposing teeth have important effects on the amount and
direction of force applied during mastication and other
mandibular clenching (bruxing) activities.
In extreme cases, the forces can cause damage to the
teeth or their supporting tissues. Forceful tooth contact
occurs routinely very near the limits or borders of
mandibular movement, thus showing the relevance of
these reference positions.

 As stated previously, tooth contact during

mandibular movement is termed the dynamic
occlusal relationship.
Gliding or sliding contacts occur during mastication
and other mandibular movements. Gliding contacts
may be advantageous or disadvantageous
depending on the teeth involved and the position of
the contacts.
The design of the restored tooth surface can have
important effects on the number and location of
occlusal contacts and must take into consideration
both static and dynamic relationships

Tooth Alignment and Dental

Arches
cusps are drawn as blunt, rounded, or pointed
projections of the crowns of the teeth. The posterior
teeth have one, two, or three cusps near the facial and
lingual surfaces of each tooth.
Cusps are separated by distinct developmental grooves
and sometimes have additional supplemental grooves
on the cusp inclines. The facial cusps are separated
from the lingual cusps by a deep groove termed the
central groove. If a tooth has multiple facial cusps or
multiple lingual cusps, the cusps are separated by facial
or lingual developmental grooves, respectively.
Depressions between the cusps are termed fossae

 Cusps in both jaws are aligned in a

roughly parabolic curve. Usually the
maxillary arch is larger than the
mandibular arch, resulting in the
maxillary cusps overlapping the
mandibular cusps when the arches
are in maximal occlusal contact

TOOTH CONTACTS DURING

MANDIBULAR MOVEMENTS
Operative dentists must design restorations capable of
withstanding the forces of mastication and clenching.
The choice of restorative material and the design of
the restoration are frequently influenced by the need
to withstand forceful contact with the opposing teeth.
Thus evaluation of the location, direction, and area of
tooth contacts during various mandibular movements
is an essential part of the preoperative evaluation of
teeth to be restored. The anterior teeth support gliding
contacts, whereas the posterior teeth support the
heavy forces applied during chewing and clenching.